Referral and Prior Authorization Requirements

             
TRICARE Standard puts the power to manage your health care in your hands by not requiring referrals. However, some services may require prior authorization.

Referrals:  Not Required
A referral is a recommendation from your health care provider to see another provider (a specialist) because the referring provider is not qualified to provide the needed service or it is outside his or her scope of practice.

With TRICARE Standard, you may see any TRICARE-authorized provider at any time for routine or specialty care without a referral from your family doctor.

For example, if you are injured, you may simply call an orthopedic specialist directly and make an appointment. With TRICARE Standard, it’s that easy.

Prior Authorization
Although referrals are not required, a provider may recommend a service or procedure that requires prior authorization. Prior authorization is the process of reviewing a service or procedure to determine whether it is medically necessary at the level of care requested.

“We want to give beneficiaries all the coverage they need,” says Army Maj. Gen. Elder Granger, Deputy Director, TRICARE Management Activity. “However, failure to get prior authorization limits our ability to offer that coverage.”

Keep in mind that prior authorization is required for any of the services listed below:

If you see a network provider, he or she will coordinate the authorization with Humana Military. Once an authorization is granted, Humana Military will also issue service beginning and ending dates for medical or surgical services. For behavioral health authorizations, Humana Military will specify a certain number of visits, in addition to the beginning and ending dates.

All authorized care must be received before the authorization’s end date. If not, your provider must acquire a new authorization.

Additional authorization rules may apply, so it's best to call them if you have questions.